The home health care nurse is visiting a child with renal failure undergoing continuous ambulatory peritoneal dialysis (CAPD). Which of the following would lead the nurse to identify a nursing diagnosis of fluid overload related to CAPD?
poor skin turgor
shortness of breath
Redness at the tube insertion site
Fever
The Correct Answer is B
A. Poor skin turgor typically indicates dehydration, not fluid overload.
B. Shortness of breath can be a sign of fluid overload, particularly in children with renal failure, as excess fluid can accumulate and lead to pulmonary edema.
C. Redness at the tube insertion site may indicate infection but does not specifically relate to fluid overload.
D. Fever is a sign of infection or inflammation and does not directly indicate fluid overload.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Weighing the child daily on the same scale is critical for monitoring fluid retention and managing edema, which are primary concerns in nephrotic syndrome.
B. Testing urine for glucose levels is not a routine part of nephrotic syndrome management, as glucose levels are not typically affected by this condition.
C. Increasing fluid intake is not advisable in nephrotic syndrome if there is significant edema; fluid management must be tailored to the child's condition.
D. While ambulation is beneficial, it is not as critical as daily weight monitoring in managing nephrotic syndrome.
Correct Answer is A
Explanation
A. The primary treatment for congenital aganglionic megacolon (Hirschsprung's disease) is surgical intervention to remove the affected segment of the bowel, allowing for normal bowel function and preventing complications such as bowel obstruction.
B. Oral iron preparations would not address the underlying condition of Hirschsprung's disease, which is related to the lack of nerve cells in the bowel.
C. While counseling may be beneficial for the caregivers regarding the diagnosis and care, it is not the primary treatment for Hirschsprung's disease.
D. While enemas may be used temporarily to relieve constipation, they are not a definitive treatment for the disease, which requires surgical correction.
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